SKIN - INTAKE FORM | Smooth Expressions

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Emergency Contact Name and Phone Number

If other, please share how.

Please tell us about your skin goals and concerns.

What skin care products are you currently using?

Describe your current skin care routine? (Morning & Evening)

Does your job or lifestyle require you to work/play outdoors?

Do you wax your facial skin on a regular basis?

If yes, when was the last time?

Have you ever had facials, chemical peels, microdermabrasion, microneedling, or any resurfacing treatments?

If yes, was it within the last 30 days?

Are you currently using Retin-A, Tretinoin, or other products containing Retin?

Are you using Benzoyl Peroxide?

Do you have any allergies or sensitivities?

Have you ever experienced a reaction to any of the following: cosmetics, medicine, iodine, shellfish, latex, pollen, food/fruit, animals, fragrance, AHAs, or sunscreens?

If yes, please explain.

Please list any vitamins, supplements, or medications you are currently taking.

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